Covered California People Living with HIVAIDS Anand Kalra

Covered California & People Living with HIV/AIDS Anand Kalra Ryan White Cross Parts Meeting – 9/3/14

About me Health Programs Administrator at Transgender Law Center not a lawyer, not a doctor, just your friendly neighborhood librarian Covered California Certified Educator and Certified Enrollment Counselor

Covered California Premiums By law, can only vary by: Age Location (19 regions) Premium assistance available to households with income <400% FPL For 2014, ~$47, 000 for individual, $96, 000 for family of four Amount of premium assistance (subsidy) inversely proportional to income Higher income less assistance

Insurers with QHPs in CC 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Anthem Blue Cross Blue Shield Chinese Community Health Plan Health Net Kaiser Permanente LA Care Health Plan Molina Healthcare Sharp Health Plan Valley Health Plan Western Health Advantage

Program Eligibility Program ADAP OA-HIPP Medi-Cal Covered CA Eligibility Requirements FAGI < $50 k, Medi-Cal ineligible Enrolled in ADAP MAGI < 138% FPL Income >138% FPL; subsidies up to 400% FPL (pro-rated)

Drug Formularies Download at: https: //www. coveredca. com/faqs/prescriptiondrugs/ Formularies the same for each “metal tier” (gold, silver, etc. ) for a given insurer Difference is deductible and copays.

Covered CA plans – formulary analysis Number of Covered CA plans that cover antiviral drugs listed in ADAP Formulary ziagen epzicom trizivir rescriptor videx, videx ec sustiva emtriva epivir zerit viread truvada hivid retrovir combivir intelence viramune edurant fuzeon stribild atripla complera agenerase reyataz prezista lexiva crixivan kaletra viracept norvir fortovase invirase aptivus selzentry isentress tivicay 10 10 10 9 10 10 0 9 8 10 10 9 10 7 9 7 0 10 10 10 9 10 0 9 9 10 10 4

Of the 35 antivirals in ADAP formulary… Insurance Carrier # of drugs covered Anthem Blue Cross 28 Blue Shield 28 Chinese Community Health Plan 30 Health Net 32 Kaiser Permanente 31 LA Care Health Plan 31 Molina Healthcare 31 Sharp Health Plan 32 Valley Health Plan 31 Western Health Advantage 22 *Medi-Cal 31

Calculating Yearly Costs For a 35 -year-old living in San Francisco who makes $17, 000, takes 4 brand drugs and 2 generics, filled 4 x yearly Item Per unit/use Yearly total Premium $377/month $4524 Premium assistance (-$314/month) (-$3768) Brand drug deductible $50 Brand drug copay $15/drug $240 Generic drug copay $5 $40 Primary care visit $0/first, $15 subsq. $30 Labs $15/visit $30 Medical deductible $500 Let’s assume 0 Total $1146

Calculating Yearly Costs Item Bronze Silver* Enhanced Silver Gold Platinum Net premium $1 $200 $70 $150 $200 Deductible $5000 $2000 $500 $0 $0 PCP visit $60 $45 $15 $30 $20 Specialty visit $70 $65 $20 $50 $40 Labs 30% $45 $15 $30 $20 Brand drugs $50 $15 Generic drugs $15 $5 Hospitalizatio n 30% 20% 15% $600/day $250/day ER copay 30% $250 $75 $250 $150 $6250 $2250 $6250 $4000 Maximum out- $6250 of-pocket Bold = subject to deductibles * Regular silver for income >250% FPL; subsidy rates are lower as income increases; this is for $30, 000

Covered CA + OA-HIPP Source: California HIV/AIDS Policy Research Centers, Policy Brief – Sept. 2013

Covered CA + OA-HIPP Application for OA-HIPP should include OA-HIPP Application Insurance Assistance Section Consent Form Insurance Assistance Section ARIES Consent Billing statement from Covered California plan Covered California Welcome Letter Not needed if billing statement includes premium assistance amount Source: Office of Aids Insurance Assistance Section Memo - OA-HIPP/Covered California Policy and Procedures, December 3, 2013; and Memo - OA-HIPP- Enrolling Clients into OA-HIPP after Obtaining Coverage Through Covered California, February 14, 2014. Download from: http: //www. cdph. ca. gov/programs/aids/Pages/OAIAS. aspx

Covered CA + OA-HIPP Timelines: before/after 15 th of month Submit January 10 effective March 1 Submit January 20 effective April 1

Covered CA + OA-HIPP Payments Initial covers 1 st month of insurance + 3 more Subsequent payments quarterly First month’s premium: If applying for insurance to start before OA processing time, patient can pay the 1 st month’s premium and request refund from insurance plan after insurance plan receives initial payment

Questions? Anand Kalra anand@transgenderlawcenter. org 415 -865 -0176, ex. 305

Thank you!